=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063906378
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DODAM ACUPUNCTURE P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2018
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6215 20TH AVE FL 1
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11204-3024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-563-5820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3622 PARSONS BLVD STE 1
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-5932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-563-5820
-----------------------------------------------------
Fax | 917-563-5819
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PRACTITIONER
-----------------------------------------------------
Name | CHANG JOON WON
-----------------------------------------------------
Credential | L.AC
-----------------------------------------------------
Telephone | 917-563-5820
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 005242
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------